New Minimum Fee Schedule for Home and Community-Based Services
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Defines the Wisconsin DHS minimum fee schedule (MFS) effective 10/01/2024 for specified adult long-term care home- and community-based services and explains required changes to authorizations, coding, modifiers, and claim submission for affected managed care programs.
A DHS minimum fee schedule for HCBS in Wisconsin with rates effective October 1, 2024 is being implemented and applies to multiple residential and non-residential services.
All residential authorizations must include a revenue code, procedure code, up to four modifiers, member LTCFS tier, and the LTCFS calculation date starting 10/1/2024.
Specific revenue codes, procedure codes, and modifier mapping for different residential settings (1-2 bed AFH, 3-4 bed AFH, CBRF, RCAC) are specified for use beginning 10/1/2024.
Non-residential services (Supportive Home Care and Self-Directed Supports) will also receive new authorizations and rates effective 10/1/2024.
Scope and Applicability of the Minimum Fee Schedule
Coverage and billing criteria for MFS
Covered and billing rules that apply to the DHS Minimum Fee Schedule (MFS) effective 10/01/2024.
Revenue Codes, Procedure Codes, and Modifier Mapping
| 0240 | All Inclusive Ancillary General Classification — Use for 1-2 Bed AFH; maps to T2031 (Assisted Living; Waiver, Per Diem); required modifiers: -U1, U2, or U3 as the first modifier; -U5 or U6 as the second modifier; -U7 as the third modifier; -U4 as the fourth modifier if applicable. |
| 0241 | All Inclusive Ancillary Basic — Use for 3-4 Bed AFH; maps to T2031 (Assisted Living; Waiver, Per Diem); required modifiers: -U1, U2, or U3 as the first modifier; -U5 or U6 as the second modifier; -U8 as the third modifier; -U4 as the fourth modifier if applicable. |
| 0242 | All Inclusive Ancillary Comprehensive — Use for a CBRF with 8 beds or fewer; maps to T2033 (Residential Care, Not Otherwise Specified, Waiver; Per Diem); required modifiers: -U1, U2, or U3 as the first modifier; -U7 as the second modifier; -U4 as the third modifier if applicable. |
| 0243 | All Inclusive Ancillary Specialty — Use for a CBRF with more than 8 beds; maps to T2033 (Residential Care, Not Otherwise Specified, Waiver; Per Diem); required modifiers: -U1, U2, or U3 as the first modifier; -U8 as the second modifier; -U4 as the third modifier if applicable. |
| 0670 | Outpatient Special Residence Charges — Use for RCAC; maps to T2033 (Residential Care, Not Otherwise Specified, Waiver; Per Diem); required modifiers: -U9 as the first modifier; -U4 as the second modifier if applicable. |
Authorization, Claim Submission, and Billing Actions Required
Residential authorization requirements (effective 10/1/2024)
As of 10/1/2024, all residential authorizations must include the following fields; authorizations with dates of service beyond 10/1/2024 will be closed and new authorizations created effective 10/1/2024.
- Revenue Code
- Procedure Code
- Modifier 1
- Modifier 2
- Modifier 3 - 4 when applicable
- Member Tier from LTCFS
- Date LTCFS was calculated
Claim submission and DOS splitting guidance
Submit claims only within the approved date range on the authorization; when services span the MFS effective date (9/30–10/1), split authorizations and claims by date of service per the provided weekly or monthly examples.
- Weekly splits example: 9/29–9/30/2024 and 10/1–10/5/2024
- Monthly splits example: 9/1–9/30/2024 and 10/1–10/31/2024
- Update service records (SR) so pre-10/1 authorization ends 9/30/2024 and a new authorization begins 10/1/2024
Key Terms and Minimum Fee Schedule Items
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